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Title. Understanding nursing on an acute stroke unit: perceptions of space, time and interprofessional practice.Aim. This paper is a report of a study conducted to uncover nurses' perceptions of the contexts of caring for acute stroke survivors.Background. Nurses coordinate and organize care and continue the rehabilitative role of physiotherapists, occupational therapists and social workers during evenings and at weekends. Healthcare professionals view the nursing role as essential, but are uncertain about its nature.Method. Ethnographic fieldwork was carried out in 2006 on a stroke unit in Canada. Interviews with nine healthcare professionals, including nurses, complemented observations of 20 healthcare professionals during patient care, team meetings and daily interactions. Analysis methods included ethnographic coding of field notes and interview transcripts.Findings. Three local domains frame how nurses understand challenges in organizing stroke care: 1) space, 2) time and 3) interprofessional practice. Structural factors force nurses to work in exceptionally close quarters. Time constraints compel them to find novel ways of providing care. Moreover, sharing of information with other members of the team enhances relationships and improves 'interprofessional collaboration'. The nurses believed that an interprofessional atmosphere is fundamental for collaborative stroke practice, despite working in a multiprofessional environment.Conclusion. Understanding how care providers conceive of and respond to space, time and interprofessionalism has the potential to improve acute stroke care. Future research focusing on nurses and other professionals as members of interprofessional teams could help inform stroke care to enhance poststroke outcomes. [ABSTRACT FROM AUTHOR]

Aim: To develop and psychometrically test the triage decision-making instrument, a tool to measure Emergency Department Registered Nurses decision-making., Design: Five phases: (1) defining the concept, (2) item generation, (3) face validity, (4) content validity and (5) pilot testing., Methods: Concept definition informed by a grounded theory study from which four domains emerged. Items relevant to the four domains were generated and revised. Face validity was established using three focus groups. The target population upon which the reliability and validity of the triage decision-making instrument was explored were triage registered nurses in emergency departments. Three expert judges assessed 89 items for content and domain designation using a 4-point scale. Psychometric properties were assessed by exploratory factor analysis, following which the names of the four domains were modified., Results: The triage decision-making instrument is a 22-item tool with four factors: clinical judgement, managing acuity, professional collaboration and creating space. Focus group data indicated support for the domains. Expert review resulted in 46 items with 100% agreement and 13 with 66% agreement. Fifty-nine items were distributed to a convenience sample of 204 triage nurses from six hospitals in 2019. The Kaiser-Meyer-Olkin measures indicated that the data were sufficient for exploratory factor analysis. Bartlett's test indicated patterned relationships among the items (X 2 (231) = 1156.69). An eigenvalue of >1.0 was used and four factors explained 48.64% of the variance. All factor loadings were ≥0.40. Internal consistency was demonstrated by Cronbach's alphas of .596 factor 1, .690 factor 2, .749 factor 3 and .822 for factor 4., Conclusion: The triage decision-making instrument meets the criteria for face validity, content validity and internal consistency. It is suitable for further testing and refinement., Impact: The instrument is a first step in quantifying triage decision-making in real-world clinical environments. The triage decision-making instrument can be used for targeted triage interventions aimed at improving throughput and staff education., Statistical Support: Dr. Tak Fung who is a member of the research team is a statistician., Statistical Methods: Development, validation and assessment of instruments/scales. Descriptive statistics., Reporting Method: STROBE cross-sectional checklist., Implications for the Profession And/or Patient Care: The TDI makes the complexity of triage decision-making visible. Identifying the influence of decision-making factors in addition to acuity that affect triage decisions will enable nurse managers and educators to develop targeted interventions and staff development initiatives. By extension, this will enhance patient care and safety., (© 2024 The Author(s). Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Introduction: There is a paucity of data evaluating early initiation of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with diabetes following acute coronary syndrome (ACS) and coronary artery bypass graft surgery (CABG)., Objectives: To describe the efficacy and safety of SGLT2i initiated early after CABG in patients with type 2 diabetes who experienced ACS., Methods: This is a retrospective cohort study of patients with type 2 diabetes (T2DM) who experienced ACS and subsequent CABG with follow up at 3 and 12 months. Patients who filled a SGLT2i prescription within 14 days of discharge were allocated to the SGLT2i group and those who did not were included in the no SGLT2i group. The primary efficacy end point was first occurrence of a 4-point Major Adverse Cardiovascular Event (MACE), and the primary safety end point was a composite of hypoglycemia, hypotension, diabetic ketoacidosis, acute kidney injury, and urinary tract infection. Secondary end points included a comparative analysis of the primary outcome, 30-day readmission rates, and subgroup analyses of key populations., Results: A total of 1629 patients were included: 226 received a SGLT2i within 14 days of discharge and 1403 did not. At 12 months, 8.9% and 15.3% of patients experienced MACE in the SGLT2i and no SGLT2i groups, respectively (adjusted Hazard Ratio [aHR] 0.65, 95% confidence interval [CI] 0.41-1.04). The primary safety outcome occurred in 12.0% of the SGLT2i group and 19.1% of the no SGLT2i group at 12 months (aHR 0.68, 95% CI 0.45-1.01)., Conclusion: Early initiation of SGLT2i use was not associated with a reduction in MACE in patients with T2DM who experienced ACS and underwent subsequent CABG surgery. However, no apparent safety concerns were identified. Adequately powered trials are required to confirm this finding., (© 2024 Pharmacotherapy Publications, Inc.)

Umbilical cord blood (CB) is a valuable source of haematopoietic stem/progenitor cells (HSCs) and is known for the therapeutic use of these cells in treating blood disorders. However, challenges such as a high running cost and the increasing availability of treatment alternatives have made the effort to sustain CB banks difficult. This prompts the need to revisit the current CB banking initiatives to retain the relevance in this ever‑changing era parallel to the fast‑pacing development of cell‑based therapeutic technology. Cellular reprogramming has shown to have successfully converted adult somatic cells into human induced pluripotent stem cells (hiPSCs), which promise wider applications in regenerative medicine, personalized treatment and tissue engineering. CB is the youngest, primitive adult cell source that has not been affected by any prior, acquired disorders. Hence, using CB as a source of candidate cells for generating hiPSCs may be a new opportunity for banking, albeit with challenges. The present review summarizes the rise and fall of CB usage and banking for clinical therapy, the considerations in reprogramming CB into hiPSCs, the safety concerns regarding the use of hiPSC‑derived cells in clinical transplantation and the prospect of using CB‑derived hiPSCs.

Objective: Patient-initiated follow-up (PIFU) for rheumatoid arthritis (RA) is a model of care delivery wherein patients contact the clinic when needed instead of having regularly scheduled follow-up. Our objective was to investigate the influence of different patient eligibility characteristics on the number of potentially deferred visits to inform future implementation of a PIFU strategy., Methods: We conducted a retrospective chart review of 7 rheumatologists' practices at 2 university-based clinics between March 1, 2021, and February 28, 2022. Data extracted included the type and frequency of visits, disease management, comorbidities, and care complexities. Stable disease was defined as remission or low disease activity with no medication changes at all visits. The influence of patient characteristics on the number of deferrable visits in patients with stable disease was explored in 4 criteria sets that were based on early disease duration, medication prescribed, presence of care complexity elements, and comorbidity burden., Results: Records from 770 visits were reviewed from 365 patients with RA (71.5% female, 70% seropositive). Among all criteria sets, the proportion of visits that could be redirected varied between 2.5% and 20.9%. The highest proportion of deferrable visits was achieved when eligibility criteria included only stable disease activity and patients with RA on conventional synthetic disease-modifying antirheumatic drugs or no medications (n = 161, 20.9%)., Conclusion: PIFU may result in a more efficient use of specialist healthcare resources. However, the applicability of such models of care and the number of deferred visits is highly dependent on patient characteristics used to establish eligibility criteria for that model. These findings should be considered when planning implementation trials., (Copyright © 2024 by the Journal of Rheumatology.)

Objective: To conduct an environmental scan and appraisal of online patient resources to support rheumatoid arthritis (RA) flare self-management., Methods: We used the Google search engine (last search March 2023) using the terms "rheumatoid arthritis" and "flare management." Additional searches targeted major arthritis organizations, as well as regional, national, and international resources. Appraisal of the resources was conducted by 2 research team members and 1 patient partner to assess the understandability and actionability of the resource using the Patient Education Materials Assessment Tool (PEMAT). Resources rating ≥ 60% in both domains by either the research team or the patient partner were further considered for content review. During content review, resources were excluded if they contained product advertisements, inaccurate information, or use of noninclusive language. If content review criteria were met, resources were designated as "highly recommended" if both patient partners and researchers' PEMAT ratings were ≥ 60%. If PEMAT ratings were divergent and had a rating ≥ 60% from only 1 group of reviewers, the resource was designated "acceptable.", Results: We identified 44 resources; 12 were excluded as they did not pass the PEMAT assessment. Fourteen resources received ratings ≥ 60% on understandability and actionability from both researchers and patient partners; 10 of these were retained following content review as "highly recommended" flare resources. Of the 18 divergent PEMAT ratings, 8 resources were retained as "acceptable" following content review., Conclusion: There is high variability in the actionability and understandability of online RA flare materials; only 23% of resources were highly recommended by researchers and patient partners., (Copyright © 2024 by the Journal of Rheumatology.)

Objective: Patients with rheumatoid arthritis (RA) may need to access rheumatology care between scheduled visits. WelTel is a virtual care platform that supports secure two-way text-messaging between patients and their health care team. The objective of the present study was to explore perspectives and experiences of health care providers (HCPs) and patients related to the use of WelTel as an adjunct to routine care., Methods: Seventy patients with RA were enrolled in a six-month WelTel pilot project launched in September 2021. Patients received monthly "How are you?" text message check-ins and could message their health care team during clinic hours to request health advice. The current project is a qualitative study of the WelTel pilot. A subgroup of pilot participants was purposively sampled and invited to participate in interviews. A thematic analysis of transcripts was conducted using a deductive approach leveraging quality of care domains., Results: Thirteen patients (62% female, mean age 62 years, 10 White) completed interviews. Patients' views suggested that text messaging with the rheumatology team supported high-quality care across multiple quality domains including patient-centeredness, timeliness, efficiency, safety, effectiveness, equity, and appropriateness. Seven HCPs (57.1% female, one pharmacist and six rheumatologists) completed interviews. HCPs' perspectives varied based on their experience with the WelTel platform. Additional themes reported by HCPs included perceived increased workload and burnout., Conclusions: Patients with RA perceived text-based messaging as supporting high-quality care. The impact of increased communications on HCP burnout and workload requires consideration, and future studies should evaluate the effect of texting on patient outcomes., (© 2024 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Background: Care complexity can occur when patients experience health challenges simultaneously with social barriers including food and/or housing insecurity, lack of transportation or other factors that impact care and patient outcomes. People with rheumatoid arthritis (RA) may experience care complexity due to the chronicity of their condition and other biopsychosocial factors. There are few standardised instruments that measure care complexity and none that measure care complexity specifically in people with RA., Objectives: We assessed the content validity of the INTERMEDS Self-Assessment (IMSA) instrument that measures care complexity with a sample of adults with RA and rheumatology healthcare providers (HCPs). Cognitive debriefing interviews utilising a reparative framework were conducted., Methods: Patient participants were recruited through two existing studies where participants agreed to be contacted about future studies. Study information was also shared through email blasts, posters and brochures at rheumatology clinic sites and trusted arthritis websites. Various rheumatology HCPs were recruited through email blasts, and divisional emails and announcements. Interviews were conducted with nine patients living with RA and five rheumatology HCPs., Results: Three main reparative themes were identified: (1) Lack of item clarity and standardisation including problems with item phrasing, inconsistency of the items and/or answer sets and noninclusive language; (2) item barrelling, where items asked about more than one issue, but only allowed a single answer choice; and (3) timeframes presented in the item or answer choices were either too long or too short, and did not fit the lived experiences of patients. Items predicting future healthcare needs were difficult to answer due to the episodic and fluctuating nature of RA., Conclusions: Despite international use of the IMSA to measure care complexity, patients with RA and rheumatology HCPs in our setting perceived that it did not have content validity for use in RA and that revision for use in this population under a reparative framework was unfeasible. Future instrument development requires an iterative cognitive debriefing and repair process with the population of interest in the early stages to ensure content validity and comprehension., Patient or Public Contribution: Patient and public contributions included both patient partners on the study team and people with RA who participated in the study. Patient partners were involved in study design, analysis and interpretation of the findings and manuscript preparation. Data analysis was structured according to emergent themes of the data that were grounded in patient perspectives and experiences., (© 2024 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Objective: An emerging strategy to address access challenges to rheumatologists for patients with RA is shared care between primary and specialist care, with patient-initiated rheumatologist follow-up as needed. The objective of this scoping review was to explore studies implementing this model of care., Methods: Four electronic databases were searched from 01/01/2000-31/03/2022 using three main concepts (RA, shared care, patient-initiated follow-up). English-language studies of any design were included if they described the implementation and/or outcomes of shared care model for RA with patient-initiated follow-up. Two authors reviewed and selected articles in duplicate and extracted data on study characteristics, care model implementation and outcomes according to a pre-specified protocol., Results: Following duplicate removal, 1578 articles were screened for inclusion and 58 underwent full-text review. Sixteen articles were included, representing 10 unique studies. Five studies had qualitative outcomes and two were pre-implementation studies. Model implementation varied significantly between studies. Effectiveness data was available in 10 studies and demonstrated equivalent outcomes for the model of care (disease activity, radiographic damage, quality of life). Health system costs were equivalent or lower than usual care. While satisfaction with care was equivalent or improved in shared care models with patient-initiated follow-up, some concerns were expressed in qualitative evaluation around appropriate patient selection for such models, and information for health equity evaluation was not reported., Conclusions: While shared care models with patient-initiated follow-up may offer comparable outcomes for RA, further work is required to understand patient preferences, health equity considerations and longer-term outcomes for such models of care., Competing Interests: Declaration of Competing Interest None of the authors have any competing interests to declare., (Copyright © 2023. Published by Elsevier Inc.)

Intimate Partner Violence (IPV) is an underrecognized healthcare phenomenon that causes significant harm to the health of those affected. The lifetime estimated global prevalence of IPV is one in three for women and one in twelve for men. Orthopaedic fracture clinics care for patients affected by IPV and, in fact, orthopaedic patients themselves believe they should be screened for IPV. Almost three percent of women seen for an acute musculoskeletal injury is a direct consequence of IPV. A major concern is that, in the absence of screening and no outward signs of IPV, healthcare providers do not screen patients. Current screening practices and policies are influenced by the nurses' practice or the organizational structure in which nurses work. The purpose of this article is to raise awareness of IPV in the orthopaedic patient population and to provide a review on IPV for orthopaedic nurses. It is important for organizational leaders to recognize the relationship between the barriers and facilitators in relation to IPV intervention. Facilitators and barriers to addressing IPV are discussed. In addition, the need to implement change in practice combined with empowering nurses to address IPV is described. Empowering orthopaedic nurses necessarily involves the provision of appropriate resources, information, and support to overcome barriers. The authors discuss unit policies, guidelines, and resources to address IPV., Competing Interests: Declaration of competing interest Declare that we have no conflict of interest in the production of the above manuscript., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: Preterm infants are at a high risk of developing BPD. Although progression in neonatal care has improved, BPD still causes significant morbidity and mortality, which can be attributed to the limited therapeutic choices for BPD. This review discusses the potential of MSC in treating BPD as well as their hurdles and possible solutions., Data Sources: The search for data was not limited to any sites but was mostly performed on all clinical trials available in ClinicalTrials.gov as well as on PubMed by applying the following keywords: lung injury, preterm, inflammation, neonatal, bronchopulmonary dysplasia and mesenchymal stem cells., Study Selections: The articles chosen for this review were collectively determined to be relevant and appropriate in discussing MSC not only as a potential treatment strategy for curbing the incidence of BPD but also including insights on problems regarding MSC treatment for BPD., Results: Clinical trials regarding the use of MSC for BPD had good results but also illustrated insights on problems to be addressed in the future regarding the treatment strategy. Despite that, the clinical trials had mostly favourable reviews., Conclusion: With BPD existing as a constant threat and there being no permanent solutions, the idea of regenerative medicine such as MSC may prove to be a breakthrough strategy when it comes to treating BPD. The success in clinical trials led to the formulation of prospective MSC-derived products such as PNEUMOSTEM®, and there is the possibility of a stem cell medication and permanent treatment for BPD in the near future., (© 2022 The Authors. The Clinical Respiratory Journal published by John Wiley & Sons Ltd.)

Objectives: The Rheumatoid Arthritis (RA) Quality of Care Survey (RAQCS) was developed to measure care quality according to a previously developed national RA quality improvement framework., Methods: The development of the RAQCS occurred over 3 phases. First, the survey was developed by a team of healthcare providers, researchers, and two patient partners based on the existing national quality framework's 21 performance measures (PMs) and strategic objectives. Second, cognitive debriefing interviews were conducted with individuals living with RA to identify survey clarity, appropriateness of survey questions, and response options. Third, the survey was revised and distributed to participants recruited from Rheum4U (rheumatology longitudinal cohort). Results were tabulated and compared with a chart audit of participant medical records., Results: Fifty-three participants completed the RAQCS. High performance (i.e., ≥70% meeting PM) was observed for 13 of 20 PMs. Lower performance was seen for the remaining PMs, which included documentation of body mass index (BMI) and smoking status, discussion of physical activity goals, comorbidity management including risk assessments for cardiovascular health and fragility fractures and disease activity assessment. There was high agreement (≥70%) between the RAQCS and chart review for 9 of 20 PMs., Conclusions: High agreement was observed between the RAQCS and chart review for selected PMs. The RAQCS may also be a valuable tool for quality improvement for measures where data are not usually available through other sources. Further testing of the RAQCS is needed to ascertain its reliability and validity as a patient self-reported tool to measure RA care quality., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Ageing and age-related diseases share some basic origin that largely converges on inflammation. Precisely, it boils down to a common pathway characterised by the appearance of a fair amount of proinflammatory cytokines known as inflammageing. Among the proposed treatment for antiageing, MSCs gained attention in recent years. Since mesenchymal stem cells (MSCs) can differentiate itself into a myriad of terminal cells, previously it was believed that these cells migrate to the site of injury and perform their therapeutic effect. However, with the more recent discovery of huge amounts of paracrine factors secreted by MSCs, it is now widely accepted that these cells do not engraft upon transplantation but rather unveil their benefits through excretion of bioactive molecules namely those involved in inflammatory and immunomodulatory activities. Conversely, the true function of these paracrine changes has not been thoroughly investigated all these years. Hence, this review will describe in detail on ways MSCs may capitalize its paracrine properties in modulating antiageing process. Through a comprehensive literature search various elements in the antiageing process, we aim to provide a novel treatment perspective of MSCs in antiageing related clinical conditions., (© 2021 International Federation for Cell Biology.)

Objective: To elucidate the essential elements of high-quality rheumatoid arthritis (RA) care in order to develop a vision statement and a set of strategic objectives for a national RA quality framework., Methods: Focus groups and interviews were conducted by experienced qualitative researchers using a semistructured interview or focus group guide with healthcare professionals, patients, clinic managers, healthcare leaders, and policy makers to obtain their perspectives on elements essential to RA care. Purposive sampling provided representation of stakeholder types and regions. Recorded data was transcribed verbatim. Two teams of 2 coders independently analyzed the deidentified transcripts using thematic analysis. Strategic objectives and the vision statement were drafted based on the overarching themes from the qualitative analysis and finalized by a working group., Results: A total of 54 stakeholders from 9 Canadian provinces participated in the project (3 focus groups and 19 interviews). Seven strategic objectives were derived from the qualitative analysis representing the following themes: (1) early access and timeliness of care; (2) evidence-informed, high-quality care for the ongoing management of RA and comorbidities; (3) availability of patient self-management tools and educational materials for shared decision making; (4) multidisciplinary care; (5) patient outcomes; (6) patient experience and satisfaction with care; and (7) equity, the last of which emerged as an overarching theme. The ultimate vision obtained was "ensuring patient-centered, high-quality care for people living with rheumatoid arthritis.", Conclusion: The 7 strategic objectives that were identified highlight priorities for RA quality of care to be used in developing the National RA Quality Measurement Framework., (Copyright © 2021 by the Journal of Rheumatology.)

Objectives: To obtain stakeholder perspectives to inform the development and implementation of a rheumatoid arthritis (RA) healthcare quality measurement framework., Design: Qualitative study using thematic analysis of focus groups and interviews., Setting: Arthritis stakeholders from across Canada including healthcare providers, persons living with RA, clinic managers and policy leaders were recruited for the focus groups and interviews., Participants: Fifty-four stakeholders from nine provinces., Interventions: Qualitative researchers led each focus group/interview using a semistructured guide; the digitally recorded data were transcribed verbatim. Two teams of two coders independently analysed the transcripts using thematic analysis., Results: Perspectives on the use of different types of measurement frameworks in healthcare were obtained. In particular, stakeholders advocated for the use of existing healthcare frameworks over frameworks developed in the business world and adapted for healthcare. Persons living with RA were less familiar with specific measurement frameworks, however, they had used existing online public forums for rating their experience and quality of healthcare provided. They viewed a standardised framework as potentially useful for assisting with monitoring the care provided to them individually. Nine guiding principles for framework development and 13 measurement themes were identified. Perceived barriers identified included access to data and concerns about how measures in the framework were developed and used. Effective approaches to framework implementation included having sound knowledge translation strategies and involving stakeholders throughout the measurement development and reporting process. Clinical models of care and health policies conducive to outcome measurement were highlighted as drivers of successful measurement initiatives., Conclusion: These important perspectives will be used to inform a healthcare quality measurement framework for RA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aim of this study was to develop a patient-centered quality measurement framework to address a predefined vision statement and 7 strategic objectives for rheumatoid arthritis (RA) care that was developed in prior qualitative work with arthritis stakeholders., Methods: One hundred forty-seven RA-related performance measures (PMs) were identified from a systematic review. A candidate list of 26 PMs meeting predefined criteria and addressing the strategic objectives previously defined was then assessed during a 3-round (R) modified Delphi. Seventeen panelists with expertise in RA, quality measurement, and/or lived experience with RA rated each PM on a 1-9 scale based on the items of importance, feasibility, and priority for inclusion in the framework during R1 and R3, with a moderated discussion in R2. PMs with median scores ≥ 7 on all 3 items without disagreement were included in the final set, which then underwent public comment., Results: Twenty-one measures were included in the final framework (15 PMs from the Delphi and 6 published system-level measures on access to care and treatment). The measures included 4 addressing early access to care and timely diagnosis, 12 evidence-based care for RA and related comorbidities, 1 addressing patient participation as an informed partner in care, and 4 on patient outcomes., Conclusion: The proposed framework builds upon existing measures capturing early access to care and treatment in RA and adds important PMs to promote high-quality RA care and outcome measurement. In the next phase, the authors will test the framework in clinical practice in addition to addressing certain areas where no suitable PMs were identified., (Copyright © 2021 by the Journal of Rheumatology.)

Introduction: In collaboration with the Alberta Medical Association's Physician Learning Program we developed individualized physician reports and held a group feedback session on rheumatoid arthritis (RA) performance measures (PM) to facilitate treat-to-target (T2T) strategies and evaluated physician experiences with this process., Methods: 5 PMs addressing T2T concepts from an established Canadian quality framework were operationalized for physician practice reports at 2 university-affiliated rheumatology clinics. Rheum4U, a quality improvement and research platform, was the data source. The audit results were reviewed in a facilitated group feedback session. Rheumatologists provided experiential feedback on the process through survey and/or an interview. Transcripts from interviews were analyzed using a 6-step thematic analysis., Results: 11 of 12 eligible rheumatologists consented to receive practice reports and provided feedback through surveys (n = 5) and interviews (n = 6). The practice reports from Rheum4U (n = 448 patients) revealed high rates of yearly follow-up (> 85%, PM1) and 100% performance on documentation of disease activity at ≥ 50% of visits (PM2). Only 34% of patients were seen within 3 months if not in remission (PM3) with 62% (2017) and 69% (2018) of those with active RA achieving a LDA state within 6 months (PM4). Approximately 70% of patients were in remission at any time point (PM5). All survey respondents agreed or strongly agreed comparison to peers was valuable and helped them reflect on their practice. Several strategies for improvement were identified, including but not limited to, leveraging of electronic records for future audit and feedback reports, providing additional granularity of results, additional stratification of results, and using high-performing peers as the comparator rather than the group mean., Conclusions: Audit and feedback was perceived by clinicians as a useful strategy for evaluating T2T efforts in RA. Future work will focus on longitudinal evaluation of the clinical impact of this quality improvement initiative.

Acute extremity compartment syndrome is considered an orthopedic emergency that has serious consequences if a correct diagnosis is not made rapidly. Patients who lose consciousness due to a drug overdose are known to collapse onto their extremities. The limbs are compressed for hours, placing them at an increased risk for acute extremity compartment syndrome and its sequelae. Compartment syndrome due to a compression of a limb from loss of consciousness secondary to drug overdose, presents unique issues to health care providers. In the setting of overdose compartment syndrome, it is similar to the more common traumatic type of compartment syndrome with respect to the pathophysiology, diagnosis and treatment. However, it differs in relation to the muscles affected, physical assessment strategy, and accurately determining the amount of the time from onset of injury to the presentation of symptoms. The purpose of this article is to facilitate emergency department nurses' understanding of the complexities of overdose compartment syndrome, combined with the importance of early recognition of the condition. In addition, the authors review the pathophysiology, the traditional and innovative diagnostic techniques, and the current treatment options available for overdose compartment syndrome., (Copyright © 2020 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Emergency Department (ED) triage decision-making is a complex process. Triage scales are used to determine patient acuity level, however, they do not provide information on how nurses make triage decisions. This focus group study was part of a larger project to develop a psychometrically sound instrument to measure triage decision-making by nurses; the Triage Decision-Making Instrument. We report important incidental findings that emerged during the study that the participants identified as factors impeding triage decision-making., Methods: Three focus groups were conducted with 11 triage Registered Nurses. They commented on the instrument items and identified factors that influence triage decision-making. Transcripts were analyzed using thematic analysis., Results: Three powerful inter-related themes emerged central to encumbering triage decision-making: competing systems (pre-hospital versus the ED), fluctuating patient volume resulting in 'intra-Canadian Triage and Acuity Scale' triaging, and personal capacity including experience and 'triage fatigue'., Discussion: The findings demonstrate how interrelated system factors impede nurses triage decision-making. Triage nurses require support in their role and initiatives are needed to reduce the pressure they feel in relation to resolving system issues. Larger system issues and the capacity of the individual decision-makers must be accounted for within the context of increasing effectiveness and safety of ED triage., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Delirium in the intensive care unit affects approximately 30% of patients despite vigorous efforts to encourage the use of effective screening tools and preventive strategies. The success of pharmacological treatment of delirium remains equivocal; moreover, a paucity of research supports the use of atypical antipsychotic medications. However, dexmedetomidine appears to have a promising role in delirium management. This review includes an overview of the pathophysiology and types of delirium and describes 2 established tools used to screen for delirium. Published research related to the use of dexmedetomidine in the management of delirium is also discussed. The authors make recommendations for critical care nurses on dexmedetomidine use in the context of providing evidence-based nursing care to intensive care unit patients with delirium., (©2019 American Association of Critical-Care Nurses.)

Objectives: To develop a web-based tool (Rheum4U) to capture clinically meaningful data to direct treatment. Rheum4U integrates longitudinal clinical data capture of rheumatoid arthritis (RA) disease activity measures and patient-reported outcomes measures (PROMs). This study tests the feasibility, acceptability and efficiency of Rheum4U among patients and healthcare providers., Methods: Rheum4U was developed in two phases: P1 design and development; and P2 pilot testing. P1: A working group of rheumatologists and researchers (n=13) performed a prioritisation exercise to determine data elements to be included in the platform. The specifications were finalised and supplied to the platform developer. Alpha testing was performed to correct initial software bugs. 18 testers (physicians, nurses and recruited non-patient lay-testers) beta tested Rheum4U for usability. P2: Rheum4U was piloted in 2 rheumatology clinics and evaluated for feasibility, efficiency and acceptability using interviews, observation and questionnaires with patients and healthcare providers., Results: 110 RA patients, 9 rheumatologists and 9 allied health providers participated in the pilot. Mean patient age was 53 years and 74% were female. The majority (86%) were satisfied or very satisfied with online data entry and 79% preferred it to paper entry. Healthcare providers found Rheum4U easy and clear to use (90%), and they perceived that it improved their job performance (91%). Completeness and easy availability of the patient information improved clinic efficiency., Conclusions: Rheum4U highlights the benefits of a web-based tool for clinical care, quality improvement and research in the clinic and this study provides valuable information to inform full platform implementation.

Inflammatory bowel disease (IBD) is a systemic, chronic autoimmune disease of the digestive tract. The etiology and pathophysiology of IBD is not fully understood, though it is believed to be due to a complex interaction among the patient's genotype, immune system, and environmental factors. Inflammatory bowel disease is frequently accompanied by extraintestinal manifestations that occur in almost half of all patients. The most common extraintestinal manifestation that occurs is joint disease, collectively termed the arthropathies of IBD. While epidemiological studies have estimated that the arthropathies of IBD occur in over 46% of the IBD population, there is a paucity of nursing literature concerning the extraintestinal manifestations of IBD and the role of nurses in patient care. Thus, the purpose of this article is to facilitate a greater understanding for nurses and nurse clinicians regarding the arthropathies associated with IBD including classifications, pathophysiology, diagnosis, and management.

Background: Triage nurses control access to the Emergency Department (ED) and make decisions about patient acuity, patient priority, and placement of the patient in the ED. Understanding the processes and strategies that triage nurses use to make decisions is therefore vital for patient safety and the operation of the ED. The aim of the current study was to generate a substantive grounded theory (GT) of decision making by emergency triage Registered Nurses (RNs)., Method: Data collection consisted of seven observations of the triage environment at three tertiary care hospitals where RNs conducted triage and twelve interviews with triage RNs. The data were analyzed by constant comparison in accordance with the classical GT method., Results: In the resultant theory, Momentary Fitting in a Fluid Environment, triage is conceptualized as a process consisting of four categories, determining acuity, anticipating needs, managing space, and creating space. The findings indicate that triage RNs continually strive to achieve fit, while simultaneously considering the individual patient and the ED as a whole entity., Conclusion: Triage RNs require appropriately designed triage environments and computer technology that enable them to secure real time knowledge of the ED to maintain situation awareness., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Emergency department (ED) wait times, length of stay, and overcrowding are common issues in developed health care systems in many countries. These ED issues are multifactorial in nature and require further evaluation in an attempt to provide consistent, adequate health care to each patient. Authors in countries, such as Australia and the United Kingdom, have attempted to address the concerns of increasing wait times, length of stay, and overcrowding by establishing nurse practitioners (NPs) into the ED who practice in domains traditionally dominated by physicians. Unfortunately, Canadian health care system leaders lack experience in implementing the unique role of the NP in the ED. In addition, emergency department fast track (FT) models have been studied and operationalized in Australia and the United States to streamline care for less acute patients. However, it is evident from review of the literature that NPs, in the Canadian health care system, are underutilized within FT units. Despite the fact that NPs have been practicing since the 1960s, there remains confusion by the public and even health care professionals about their role, scope of practice, and capabilities. The purpose of this article is to provide a greater understanding of the NP role in Canada with the intent to elucidate current barriers and facilitators to having NPs practice in the ED setting through appraisal of national and international literature sources. The article also illustrates how FT units streamline patient care and are suitable areas for NP practice within the ED. In addition, the authors describe how assessment, implementation, and evaluation of the role of NPs in the ED might be facilitated through the use of a Participatory Evidence-informed Patient-focused Process for Advanced practice nursing role development, implementation, and evaluation (PEPPA framework).

Endovascular aortic repair is a relatively new surgical technique used to treat a variety of aortic pathologies. Aortic coarctation traditionally has been managed with open surgical repair, involving a large posterolateral thoracotomy, cardiopulmonary bypass, and replacement of the narrowed section of the aorta with a dacron graft. Recent advances in minimally invasive aortic surgery have allowed for repair of the diseased section with an endovascular stent placed percutaneously through the groin under intraoperative fluoroscopic guidance. In this paper, the authors willfocus on the implicationsfor postoperative nursing care after endovascular repair of aortic coarctation using a case study of a 17-year-old male. This novel technique required education of the health care team with respect to implications for practice, understanding potential complications, discharge planning and follow-up. With any new surgical technique there are many questions and challenges that health care professionals raise. The main concerns expressed from the health care team stemmed from a lack of understanding of the disease pathology, and the different risk profile associated with an endovascular repair in contrast to an open repair. The authors will address these concerns in detail.

The focus group research method has been used in a variety of settings over the years. The method of using group interviews was described as long ago as 1926. Focus groups have been used by large corporations to gather the public's opinions regarding their products. In the past 20 years the focus group method has been increasingly used in health care research in a variety of settings. Researchers use the focus group method in order to obtain in-depth knowledge concerning attitudes, perceptions, beliefs and opinions of individuals regarding a specific health issue. The purpose of this article is to provide a review of the focus group research method. The authors discuss the process, analysis, advantages and disadvantages of this qualitative method.

Introduction: Emergency nurses deal with increasing complexity of patients. In 2003 there were over 14 million ED visits in Canada. The Canadian Triage and Acuity Scale (CTAS) is a 5-level system used by ED triage nurses to classify patients. There is a need for standardized training for all triage systems. In an effort to improve access to CTAS training, a 6-week Web-based CTAS workshop was developed. We determined the impact of Web learning on the accuracy of the triage skills of registered nurses (RNs)., Methods: An experimental method was used in which 132 RNs were randomized to an intervention group (n = 65) or control group (n = 67). All RNs received exactly the same content and learning activities. The experimental group differed from the control group in 3 ways: a mandatory tutorial, awarding of marks for online discussion, and completion of a workplace project. Data were collected using standard instruments, chart audit, and interviews., Results: The Web course provided a standardized and effective educational experience that enhanced emergency nurses' triage accuracy. The mandatory online tutorial, online discussion, and workplace project increased the RNs' preparation for online learning, and these educational methods were successful in transferring triage learning to practice., Discussion: Web learning can help professionals maintain competency and support professional practice. Further research is needed to provide evidence for best practices in E-learning for RNs. The accuracy of the RN's triage assessment impacts patient health, hospital accreditation, and funding., (Copyright © 2013 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.)

Background: The purpose was to examine the relationship between the complexity of structural heart disease and psychological well-being in adults with congenital cardiac disease., Methods: A total of 380 patients registered at the Adult Congenital Heart Clinic in Calgary, Alberta, Canada were surveyed. The patients were mailed a socio-demographic questionnaire and an instrument to measure psychological well-being. The instrument of psychological well-being measures six dimensions: positive relations with others, autonomy, environmental mastery, personal growth, purpose in life, and self-acceptance. Of the 380 patients surveyed, 85 of 205 patients with simple structural malformation responded, giving a response rate of 41%, and 78 of 175 patients with complex malformations, thus giving a response of 45%., Results: There was no statistically significant difference in the mean scores of each of the six dimensions of psychological well-being between those patients with simple and complex malformations. Two-way analysis of variance, and multivariate analysis of variance, found significant differences in mean scores for dimensions when other socio-demographic variables were included in the analysis. For example, significantly higher mean scores for the dimension of purpose in life was found in patients who obtained a higher level of education (p = 0.009), and in patients who were employed (p < 0.001). We present the socio-demographic variables that statistically impact the mean scores for the dimension of psychological well-being., Conclusion: Psychological well-being is not affected by the complexity of the structural congenital cardiac disease. Certain socio-demographic variables that impact psychological well-being, nonetheless, must be considered when developing multidisciplinary programmes to care for young adults with congenitally malformed hearts.

Introduction: There is increasing interest in 5-level triage systems in emergency departments; however, the adoption of a new system places heavy training demands on ED department nurses and physicians. One emerging training option is online learning. The purpose of this study was to explore the effectiveness of an online course in the 5-level Canadian Triage and Acuity Scale (CTAS) on the clinical practice of the triage nurse., Methods: Interviews were held with 23 emergency nurses from across Canada. A chart audit of triage codes from 367 charts from 6 hospitals was conducted., Results: The most consistent finding was that the majority of RN staff enjoyed the online course and believed it had improved their triage practice. Nurses believed that their patient assessments were more thorough, accurate, and consistent throughout the department. Improved communication between staff and with patients and families was identified. Nurses reported using what they learned to improve triage assessment. Triage accuracy was high; the overall agreement between CTAS graduates and the chart auditor/expert within one CTAS level was 99.7%. Nurses also identified a number of organizational barriers to CTAS implementation after the course., Discussion: The online format appears to be an effective, efficient, and convenient way to educate large numbers of ED staff in CTAS. Further research is needed regarding the use of multimedia and computer online chat options to further enhance the online learning experience for nurses.

Approximately 84% of all stroke patients with hemiplegia will experience shoulder injury and pain. The importance of maintaining proper posture while positioning and transferring a stroke patient is key to decreasing risk for shoulder injury. Shoulder subluxation injury post-stroke is a consequence of sustained hemiplegia and spasticity. Current research evidence suggests that using therapies such as gentle range of motion and functional electrical stimulation may reduce and prevent shoulder subluxation and hemiplegic shoulder pain. However, physiotherapists are currently the only professionals who can implement such therapies. Considering that stroke care provided by neuroscience nurses includes transferring, positioning and assisting in activities of daily living, it is clear that nurses are an important part of the therapy process. Therefore, the question is: "What is the role of the neuroscience nurse in the reduction and prevention of shoulder pain post-stroke?" The purposes of this paper are to i) discuss the causes of shoulder subluxation and related pain post-stroke, ii) review current best practice in prevention and treatment of shoulder subluxation, and iii) explore ways in which the acute neuroscience nurse can prevent or reduce shoulder subluxation in the hemiplegic stroke patient.

Despite the existence of a variety of consistent hypertension guidelines,the issue of inadequate management of the condition persists. The challenge for health care professionals is not only to understand and adopt the guidelines but also to take a holistic approach to patient care. In addition, clinicians need to encourage adherence to medication protocols, which will hopefully lead to an overall reduction in morbidity and mortality associated with hypertension. It is the clinician's professional responsibility to be cognizant of the emerging research on vasoactive substances as new drugs are being developed that will effect endothelial receptors. It is important that clinicians are trained appropriately in blood pressure measurement and risk factor identification and intervention.

Objective: The purpose of this study was to compare the clinical manifestations of first-time acute myocardial infarction (AMI) in 3 age groups of men and women who presented to the emergency departments of 3 acute tertiary care hospitals., Design: An exploratory, descriptive design was used, and there were 2 phases to the project. Phase 1 was a retrospective chart audit of a systematic random sample of patient charts, and phase 2 included a structured interview of a prospective random sample of emergency and intensive care unit nurses and physicians. The data were collected by using a chart audit tool and a semistructured interview, respectively., Setting: The study took place at a western Canada university affiliated with acute tertiary care centres., Sample: A systematic random sample of 153 (105 men and 48 women) patient charts were audited from the health records departments of 3 acute care hospitals. All of the patients had experienced a first-time AMI. In addition, a random sample of emergency/intensive care unit nurses (n = 60) and physicians (n = 18) was interviewed., Results: The results indicate that a statistically significant number of the oldest (75 years or older) male patients present with atypical manifestations of AMI compared with the men in the younger age groups (P =.005). The same trend was not noted for female patients. The results of the study are limited with respect to the small number of women in each age category. Caution must therefore be exercised in generalizing the results to the target population of women with AMI. The atypical manifestations are described. The results of the interviews revealed that many clinicians do not look for different clinical manifestations when assessing older patients., Conclusions: It is essential that nurses and physicians accurately assess patients with AMI, especially patients in the older age groups who may be presenting atypically. It is also important that professional and nonprofessional public health education initiatives include information regarding both typical and atypical presentation of AMI, particularly in the older patient.